Page 15 - Law And Rules Regarding Medical Record
P. 15
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i. Proper Documentation
Tips for - record keeping
• Medical records can contain a wide range of material, such as handwritten notes,
computerised records, correspondence between health professionals, lab reports, imaging
records, photographs, video and other recordings and printouts from monitoring
equipment.
• Do not write offensive or gratuitous comments – eg, racist, sexist or ageist remarks.
➢Only include things that are relevant to the health record.
